Child and Adolescent Psychiatry
Module
Week 1
Dr Sarah Huline-Dickens
Consultant in Child Psychiatry,
Mount Gould Hospital, Plymouth
[email protected]
Introductions
•
•
•
•
To group
To module
To ground rules
To reading list
Learning Objectives for Today
this morning…
•
•
•
Describe a typical CAMHS
Describe the continuities of childhood disorders
into adult life
Describe the classification systems used and the
aetiology and epidemiology of the major
psychiatric disorders of childhood and
adolescence
Learning Objectives for Today
this afternoon…
•
Recall the principles of attachment theory
•
Describe the features of the disorders of
development (ASD and ADHD) and their
treatment including indications for drug
treatment
Session content
•
•
•
•
•
•
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Introduction to child psychiatry and CAMHS
Continuities into adult life (group work)
Classification, epidemiology and aetiology
Lunch
Attachment theory (group work)
Break
Developmental disorders: ADHD and ASD (mock
CASC and video)
• Finish at 4pm
What’s it like for a new boy?
CAMHS 1
• Based in Mount Gould Hospital
• Erme House is for out-patients
• The Terraces is a day unit for under 13s
with severe problems (4 week assessment)
• Out-patient clinics
• COT, a crisis intervention team
• Cotehele, the regional adolescent unit,
opened January 2007
CAMHS 2
• Multidisciplinary team
• Single point of entry with primary mental
health workers (tier 2)
• Choice and partnership system
• Some specialist clinics
What is a psychiatric disorder?
An impairing abnormality of behaviour, emotions
and relationships
• ABNORMAL in relation to:
– child’s age and gender
– developmental stage
– culture
– persistence
– extent of disturbance
– severity and frequency
• IMPAIRMENT
– causes suffering to
child/distress to family
– social restriction
– impedes the child’s
development
– effects on others
What kinds of disorders?
• Emotional disorders (internalizing)
–
–
–
–
–
anxiety disorders
phobias
depression
OCD
Some somatisation
• Disruptive behavioural disorders (externalizing)
– hyperkinetic disorder/ADHD
– conduct disorder
What kinds of disorders?cont’d
• Developmental disorders
-speech/language delay
-reading delay
-autistic disorders
-generalised learning disabilities
-enuresis and encopresis
• Adult onset disorders
-psychosis
-eating disorders
-mood disorders, DSH
How common are they?
Prevalence of some psychiatric disorders:
Conduct disorder 5-10%
Hyperkinetic disorder 1-5%
Anorexia nervosa 0.1-0.7% of adolescent girls
Autism 2 per 1000
-
See Ford T (2008) JCPP 49:9 p900-914
Continuity into adult life
Tasks:
• Group 1 prepare for a radio interview
• Group 2 think about how you would devise
a teaching session based on this information
for paediatricians
• Group 3 consider how you would make a
poster with the key messages
Epidemiology 1
• National or local cohort
studies e.g. Dunedin (NZ)
study for 1972-3 births
• Melzer (2000) Child
Mental Health Survey
used child benefit records.
10% of children up to 16
had an ICD 10 diagnosis.
Strong association with
social class. Follow-up
showed only 20% in
contact with specialist
services
• Local population
surveys e.g. Isle of
Wight, Ontario,
Waltham Forest,
Puerto Rico
Epidemiology 2
• Pre-school: Richman (1982) Waltham Forest 3year- olds. Overall rate 22%. Severe behavioural
and emotional problems 7%.
• Middle Childhood: Rutter (1979) Isle of Wight
10-11- year- olds. Overall rate 7% (double in
London). Important associations with parental
psychiatric disorder, learning disability and
physical health (especially epilepsy). Boys exceed
girls. Problems tend to persist. Mainly conduct
and emotional disorders.
Epidemiology 3
• Adolescents: rates of depression rise
dramatically in girls and deliberate selfharm emerges
• Rate probably 15-20% but studies vary in
criteria used
• Adolescent turmoil is not universal
Epidemiology 4
• Many disorders co morbid
• Most untreated
• Many persistent, especially conduct
problems
• Marked gender differences
Classification
•
•
•
ICD 10
DSM IV
Both have multi-axial schemes:
1.
2.
3.
4.
5.
6.
Psychiatric disorder
Specific delay in development
Intellectual level
Medical condition
Psychosocial adversity
Adaptive functioning
Classification 2
•
•
•
•
But…
Ever increasing complexity
High rates of comorbidity
High use of NEC by clinicians mean this may be
revised
• So instead of 16 DSM and 10 ICD 10 chapters
likely to be 5 large groups in the future
(neurocognitive, neurodevelopmental, psychoses,
emotional and externalising disorders)
•
See Goldberg D (2010) BJPsych 196 p 255-256
Aetiology 1
• the genetics of common mental disorders
• gene – environment interactions
• environmental factors that modify HPA
sensitivity
• the biology of good and bad attachment
experiences
• the later effects of childhood abuse
•
(these 3 slides courtesy of Goldberg 2009)
Aetiology 2
Genes control…….
• Hormones, neurotransmitters and immune
responses
• The tendency to experience anxious symptoms;
and conversely general resilience to life stress –
but there is an important G x E interaction here
• About half – sometimes more - of the variance of
major personality types; but environmental factors
also play a part
Aetiology 3
Factors in life increasing the incidence rates for
CMD by increasing HPA sensitivity:
Severe early deprivation [orphanage reared
children]
∙ Maternal deprivation
∙ Maternal depression
∙ Sexual and physical abuse during childhood
(not only depression & anxiety, also eating
disorders and poor sexual adjustment) see Glaser,
D. (2000) JCPP, 41, 1, p 97-116
Aetiology 4
•
Child
–
–
–
–
–
–
•
Family
–
–
–
–
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boys
low intelligence
difficult temperament
physical illness
developmental delay
genetic factors
•
traumatic stress
ineffectual parenting style
overprotective parenting
marital disharmony
maternal ill-health
paternal psychiatric disturbance
abuse
Environment
–
–
–
–
peer relationship problems
social deprivation
school factors
stresses resulting from accidents
Aetiology 5
• Consider whether child, family,
environmental factors are:
– PREDISPOSING
– PRECIPITATING
– PERPETUATING
• What is protective and aiding resilience?
•
•
1)
2)
3)
Aetiology 6
Nature vs. nurture becomes nature
and nurture
Genetic factors are important in autism, bipolar affective
disorders, schizophrenia, tic disorders, and probably
hyperactivity
Genetic liability may translate into poorer outcomes
through:
leading directly to psychopathology e.g. autism;
confering greater susceptibility to less favourable
environments;
causing individual to seek out risk situations/ behaviours
Lunch!
Resume of this morning
• What did you learn?
Quiz
Q1
• The following statements concerning conduct disorder
are true:
• A it is the most prevalent child psychiatric disorder
• B antisocial behaviour associated with personality
abnormalities is more likely to be solitary than socialised
• C delinquency is a synonymous term
• D reading retardation is significantly associated
• E prognosis is good
Q2
• In the Isle of White child psychiatry study:
• A the prevalence of psychiatric disorder in boys was twice
that in girls
• B the prevalence of psychiatric disorder increased as
intelligence decreased
• C uncomplicated epilepsy was not a significant risk factor
• D 4 years later over half were still handicapped by their
problems
• E the subsequent inner London survey showed broadly
similar rates
Q3
• Epidemiological studies of children and adolescents
have generally shown that:
• A 25-40% have a psychiatric disorder
• B autistic disorders are one of the commonest child
psychiatric disorders
• C children with conduct problems only rarely have
emotional problems too
• D most children with psychiatric disorders are in contact
with mental health professionals
• E psychosocial disorders have become less common over
recent decades
Attachment theory
• In groups summarise in 20 words what you
understand by attachment theory
Attachment
• Bowlby (1907-1990)
• Ethology (the biological study of
behavioural processes)
• Need to be attached as important as other
needs (see Harlow 1965)
• Internal working models generated which
influence relationships and attitudes
throughout life
Attachment 2
• Mary Ainsworth’s Strange Situation Procedure in
12-18 month children
• 7 phase experiment to assess attachment status
with carer and stranger present involving two brief
separations and reunions
• A= avoidant
• B=secure
• C=resistant/ambivalent
• D=disorganised/disorientated
Attachment 3
• Importance throughout life
• Mary Main’s Adult Attachment Interview draws upon
discourse analysis to rate state of mind concerning
attachments
• Parent and infant attachment styles correspond highly (2/3
match)
• Secure infants tend to be happy infants
• In adult clinical samples likelihood of secure attachment is
10%
Attachment 4
• Interesting work on mentalising (ability to
work out people’s mental states) and
attachment (Fonagy) i.e. insecure infants are
less likely to be able to think in situations of
anger or arousal and fall apart
• Secure attachment is maintaining the
balance between inhibiting thought about
others and feeling strongly for them
Attachment 4
• Contrast with attachment disorder (much rarer)
which is pervasive and severe and results in
distress
• Recognised in ICD 10 and DSM IV as disinhibited
or inhibited type
• Differentiate from: ADHD, mania, frontal lobe
conditions, ASD
• Can result in problems with relationships,
behavioural problems and cognitive development
ADHD 1 (hyperkinetic disorder,
hyperactivity)
• Core features: triad of restlessness, impulsivity and
inattentiveness
• Pervasive
• Early onset by 7 years
• Prevalence 3-5%. Male: female 3:1
• Linked with deprivation
• Comorbidity very common (conduct, poor peer
relationships, learning problems, clumsiness and
developmental disorders but no demonstrable brain
damage)
• Aetiology unclear: seems to be heritable. Idea of a
dopamine transfer deficit.
ADHD 2
• Management: must exclude other reasons for hyperactive
behaviour
• MTA study (1999) confirmed use of stimulants more
effective than other treatments
• Educational measures
• Diet: unclear benefit
• Stimulants, most commonly methylphenidate acting as
indirect sympathomimetic agents ↑DA (side effects:
appetite suppression, tics, sleep disturbance, need to
monitor growth, but not addictive)
• Prognosis: most will improve in symptoms in adolescence,
but a minority will still be restless and inattentive adults
Pervasive developmental
disorders (communication
disorders, autistic spectrum
disorders) 1
• Prevalence 2 per 1000
have PDD
• For autism 0.5 per 1000
• Male: female ratio 3:1
• No clear association
with socio-economic
status
• Triad of: social
impairment,
communication
problems and
restrictive/ repetitive
interests and
behaviours
• Early onset (before 36
months)
Pervasive developmental
disorders (communication
disorders, autistic spectrum
disorders) 2
• Associated features:
• Mental retardation
(verbal IQ lower than
non-verbal IQ)
• Seizures in a third of
mentally retarded
• Hyperactivity common
• Self-injury
Pervasive developmental
disorders (communication
disorders, autistic spectrum
disorders) 3
•
•
•
•
•
Differentiate from:
Language disorders
Asperger’s syndrome
Mental retardation
Rett’s syndrome (girls,
regression at 12 months,
‘hand-washing stereotypies
and overbreathing, death
often before 30)
• Neurodegenerative
disorders
• Extreme early
deprivation
• Deafness!
Pervasive developmental
disorders (communication
disorders, autistic spectrum
disorders) 4
• Aetiology: genetic (twin heritability 90%)
• Psychological deficit: ?theory of mind
(Sally Anne test) ?executive function
• Treatment: educational interventions.
Some role for psychotropic medication
Pervasive developmental disorders
(communication disorders, autistic
spectrum disorders) 5
• Indications for drug treatment:
• Mainly aggression (more common in
marked intellectual retardation and impaired
communication and poor living skills)
• If specialised education, behaviour therapy
and environmental change fail
• Treat comorbidity e.g. ADHD or depression
Pervasive developmental disorders
(communication disorders, autistic
spectrum disorders) 6
• Recent studies have shown benefit of risperidone
in autism* in aggression
• Adverse events: somnolence, EPS, weight gain,
raised prolactin
• Not licensed for irritability in UK (although is in
US)
• Monitoring needed (see review: growth, BP,
behaviour, EPS)
• * see BMJ 2007; 334:1069-70 for review (Morgan & Taylor)
Pervasive developmental
disorders (communication
disorders, autistic spectrum
disorders) 4
• Aetiology: genetic (twin heritability 90%)
• Psychological deficit: ?theory of mind
(Sally Anne test) ?executive function
• Treatment: educational interventions.
Some role for psychotropic medication
Quiz
Q4
• Children with a disinhibited attachment
disorder commonly show:
• A attention-seeking behaviour
• B hypervigilance
• C reduced need for sleep
• D indiscriminate friendliness
• E aggression in response to another person’s
distress
Q5
• Hyperactivity is:
• A usually associated with a history of parental
neglect
• B commonly associated with demonstrable brain
damage
• C more frequent in those with epilepsy
• D associated with other developmental disorders
• E commoner in children reared in institutions from
infancy
Q6
• The following are characteristic of infantile
autism:
• A poor understanding of speech
• B echolalia
• C hallucinations
• D poor eye-to-eye gaze
• E pronominal reversal
Management 1
• The importance of the biopsychosocial approach
• Indications for out-patient, day patient and
inpatient care
• Think about risk assessments
• Mention NICE guidelines (ADHD, eating
disorders, depression in young people, atypical
anti-psychotics, DSH) or strategic documents (e.g.
national autism plan for children)
Management 2
• Investigations: information (old notes, GP,
informants), psychological, medical, social
• Short, medium and long-term
• Prognosis: the condition in general and this
particular patient
Learning Objectives for today
• Describe a typical CAMHS
• Describe the continuities of childhood
disorders into adult life
• Describe the classification systems used ,
and the aetiology and epidemiology of the
major psychiatric disorders of childhood
and adolescence
Learning Objectives for today
cont’d
• Recall the principles of attachment theory
• Describe the features of the disorders of
development (ASD and ADHD) and their
treatment including indications for drug
treatment
The End
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Dr Huline-Dickens - the Peninsula MRCPsych Course